Improving maternal outcomes in rural and remote communities

The health gap between Indigenous and non-Indigenous people starts at birth. The target to halve the gap in child mortality rates is not on track. In fact, it has widened to 2.4 times higher for Indigenous children.

Preterm births are also higher for Indigenous women, which can lead to childhood disability and potentially chronic diseases in later life, including diabetes, cardiovascular disease and renal disease.

One reason put forward for these poor outcomes is access to care in rural and remote regions.

“Access is not just about physical access – you know, where something is close enough that you can get to it – [but also] whether services are accessible for people and acceptable,” says Dr Geoffrey Clark of James Cook University.

“And then it’s also about the availability of the service when you need it. You might, for example, have a great midwifery group practice, but if the numbers that the midwifery group practice can take are limited and you can’t get in, then there’s no availability, even though the service exists.

“So, accessibility takes in lots of factors.”

As it stands, Aboriginal and Torres Strait Islander women are three times more likely to die as non-Indigenous women, with a maternal mortality ratio of 16.4 deaths per 100,000 Indigenous births.

Clark takes issue with current polices that state women in rural and remote areas must move to the nearest city at 36 weeks.

“They’re uplifted in RFDS aircraft normally and flown to wherever they’re going to give birth, and they wait in a hostel until such times as they have their baby.

“So quite often, this is ... why people don’t turn up at 36 weeks, because they don’t want to be taken away from their family. And that’s understandable when you understand the strong link between birthing on country and the cultural identity of Indigenous people,” Clark says.

Improving outcomes
Academics argue that increasing term birth will impact all other Close the Gap targets such as life expectancy, literacy, Year 12 completion and employment targets. Babies born preterm can be at risk of developmental delays that impact school readiness and attainment.

Sue Kildea and Yvette Roe from the Molly Wardaguga Research Centre, College of Nursing and Midwifery, at Charles Darwin University, insist that a lack of Indigenous input into health services is another reason for poor outcomes.

“If you don’t have Aboriginal and Torres Strait Island people at the table helping to design the services, then it’s not surprising that they don’t necessarily meet the need, which means they’re just not appropriate in many instances,” Kildea says.

“Once the Aboriginal and Torres Strait Island community is engaged, they’ve got to be at the table in the planning, in the co-design, in the implementation and in the monitoring. That’s why embedding a community governance and control is so important,” Roe says.

The two women have worked on a scheme aimed at reducing preterm births called ‘Birthing in Our Community’.

Based in Queensland, the maternity support program has halved the odds of preterm births for Aboriginal and Torres Strait Islander women compared to those receiving standard care. The women in the program received their own midwife, help with transport, food and financial support if needed.

The service was run in conjunction with the Institute for Urban Indigenous Health, the Aboriginal and Torres Strait Islander Community Health Service and Mater Health, all of which pooled resources, with the Queensland government eventually coming on board with more funding.

“Having a community hub that’s funded and supported by two community-controlled health organisations has been critical,” Roe says.

“The women are saying, ‘We feel this is our space.’ Again, it hasn’t got the sort of smell and feel of the hospital. Women feel this is our community, in the community, so that’s been really critical.”

Kildea and Roe don’t single out one part of the service that helps most; instead, each small detail creates the environment for safe and successful birthing.

“We think, at this stage, it wouldn’t be advisable to try and take bits of those pieces out, because all of them have a strong evidence base behind them,” Kildea says.

Using the results and insights gleaned from the service, Kildea, Roe and others have developed the RISE framework.

RISE stands for Redesign the health service, Invest in the workforce, Strengthen families, and Embed Aboriginal and/or Torres Strait Islander community governance and control.

“We don’t know exactly what has worked so well here, but we know that the combination has worked really well. We don’t want to sit back and wait 17 years to see research put into practice, and see another one of these services set up,” Kildea says.

“We are pretty convinced that you actually have to do all four of them. You can’t take one or two and not the others, because they’re so reliant on each other.

“What we’d like to do is get some larger-scale funding to be able to help services to move much faster, to embedding and implementing service models like this.”

A key tenet of the ‘birthing on country’ service is the I in RISE. This is centred on building an Indigenous and culturally capable non-Indigenous workforce. The bond created between the women involved and their midwives has been integral to the success of the service.

White scientific view of risk
When looking at current models of care, it is easy to forget that one size does not fit all.

“It’s a white scientific view of risk,” is how Clark puts it.

“Part of that is around what’s acceptable, and what’s acceptable from the point of view of risk, and because we think of risk in terms of a non-Indigenous perspective of risk, and that doesn’t necessarily accord with everyone’s idea of what risk is.”

Roe and Kildea agree. They argue that, going forward, any successful health service must involve co-design and implementation.

“We’ve had decades where health systems have been imposed on communities. And so now we’ve got systems that communities are at the table designing, monitoring and refining,” Kildea says.

Clark’s work at JCU involves mapping using geographical information to access physical accessibility. The data obtained will be used to improve services for consumers and support the effective allocation of resources for both urban and rural populations.

“One of the things that we’re interested in doing is looking at mapping – particularly in North Queensland, where of course we have some of the highest Indigenous population rates. Indigenous people accounted for more than 10 per cent of the births in Queensland last year,” Clark says.

“This is around trying to look at it from a pure access point of view. Where are services and where do people live? But then overlaying over the top of that acceptability.

“So, you can do geo-social mapping that shows from post codes how far people have to travel to a service. But then if you overlay that with ‘acceptability’ and find out where the acceptable services are, you can often get a very different picture of accessibility.”

For Kildea and Roe, RISE and the ideas behind birthing on country can be used elsewhere as part of a common-sense approach to maternal safety.

“It can be definitely customised. Can we do this for women on Sydney’s North Shore? Definitely,” Roe says.

“We know that addressing the cultural and social determinants of health, regardless of Aboriginal/Torres Strait Islander status, is a key area, and that’s often outside the birth practice.

“Strengthening family capacity and community engagement is really important. They’re things people often don’t think about when you’re talking about maternity services. Being innovative and having leadership and strength-based problem solutions is critical.”

Kildea and Roe hope to see more funding for the service. If the government funds health systems now, it will save down the track by reducing the poor health outcomes of communities.

“If we can give how much a preterm baby costs the system ... You could start at $90,000 to $300,000 for one three-term baby in hospital,” Kildea says.

“And that’s not taking into account any of the downstream costs,” Roe says. "We know that preterm babies are much more likely to need readmission in the first year of life.

“They’re more likely to get diarrhoea and respiratory tract infections. Cognitively, at school, they don’t do so well and can sometimes have hearing troubles, and they’ve ongoing help for hearing and eyesight, and other conditions that are associated with prematurity.”

“Actually,” says Kildea, “this is a social investment in choosing healthy babies and allowing them to flourish. We believe the birthing on country program is the best start to life for baby and mum.

“Birthing is such a crucial part of a journey in a person’s life,” says Roe. “It’s important to get it right.”